Form 1069 - Application For Appointment As Official Delaware Cigarette Stamp Affixing Agent Or Wholesale Dealer

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APPLICATION FOR APPOINTMENT
as
OFFICIAL DELAWARE CIGARETTE STAMP AFFIXING AGENT OR WHOLESALE DEALER
Dealer Name
_________________________________________________________________________________
Street ________________________________________________________________________________________
City, State, Zip __________________________________________________ Phone ________________________
Location of Establishment:
Street ________________________________________________________________________________________
City, State, Zip ___________________________________________________ Phone _______________________
 Vending Machine Operator
 Partnership
 Direct Buyer
 Association
 Wholesale Dealer
 Corporation
 Manufacturer
 Other:
If Corporation:
President ___________________________________ V. President ______________________________________
Home
___________________________________
Home
______________________________________
Office ___________________________________
Office ______________________________________
Secretary ___________________________________Treasurer _______________________________________
Home ____________________________________
Home ______________________________________
Office ____________________________________
Office ______________________________________
If Partnership – List All Partners:
Partner ____________________________________ Partner _________________________________________
Home ___________________________________
Home ______________________________________
Office ___________________________________
Office ______________________________________
Partner ____________________________________ Partner _________________________________________
Home ___________________________________
Home ______________________________________
Office ___________________________________
Office ______________________________________
Bank where principal business is conducted:
Bank _____________________________________ Bank __________________________________________
Address _________________________________
Address ____________________________________
_________________________________
____________________________________
Other Requirements:
1. Current Financial Statement
2. Corporations doing business in the State of Delaware must be properly registered with the Secretary of State.
3. Corporation or Partnership tax returns are required by all companies doing business in Delaware.
4. Required Business Licenses.
Form 1069

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